Timely initiation of breastfeeding among women who gave birth by cesarean section in central Ethiopia, 2022: A cross-sectional study

Background Timely initiation of breastfeeding reduces the risk of neonatal mortality. However, there was paucity of literature on the timely initiation of breastfeeding among women who gave birth by cesarean section (CS) in Ethiopia. Thus, the aim of this study was to assess the magnitude of timely initiation of breastfeeding and factors associated with it among women who gave birth by CS in central Ethiopia. Methods A facility-based cross-sectional study was conducted among 403 women who gave birth by CS. Data were collected by using an interviewer-administered questionnaire and observation checklist, entered into EpiData 4.6, and exported to statistical package for the social sciences (SPSS) version 26.Descriptive and multivariate logistic regression analyses were performed and statistical significance is declared at p<0.05. Results The magnitude of timely initiation of breastfeeding was 47.4% [95% CI: (42.5, 52.6)]. Attending four or more antenatal care visits [(AOR): 2.27, 95%CI: (1.28, 4.02)], counseling during antenatal care [AOR: 4.78, 95% CI: (2.66, 8.60)], early skin to skin contact with newborn [AOR: 2.83, 95% CI: (1.60, 5.02)], post-delivery counseling [AOR: 2.93, 95% CI: (1.56, 5.50)], and getting assistance from health professionals [AOR: 3.07, 95% CI: (1.64, 5.75)] were factors associated with timely initiation of breastfeeding. Conclusions The magnitude of timely initiation of breastfeeding in the study area was low. Strengthening counseling by health care practitioners during ANC and post-natal period should be prioritized to support women in initiating early skin-to-skin contact within one hour of birth is mandatory.


Introduction
Breastfeeding is one of the most practical and inexpensive approaches to reducing infant mortality and morbidity [1].The World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF) recommended the timely initiation of breastfeeding [2].Timely initiation of breastfeeding (TIBF) is starting breastfeeding for newborns within one hour of delivery [3], including colostrum feeding which is richer in nutrients and antibodies [4].
TIBF has a role in the survival and health of both mother and newborn.For the newborn, it creates a special bond with mother, improves cognitive development, decreases the risk of infection and sudden infant death syndrome while for the mother, the baby's suckling stimulates the production of hormones, which motivate the uterus to contract, and reduce the risk of postpartum bleeding, earlier return to pre-pregnancy weight, prevents breast engorgement, and reduces the risk of breast cancer later in her life [3,5].It is one of the approaches to reduce neonatal mortality globally [6] which contributes to nearly half of under-five mortality [7].It has been shown to reduce neonatal mortality by 22% [8].Newborns who started breastfeeding after one hour of birth were 33% more at risk for mortality [9].
Cesarean sections (CS) delivery significantly increased throughout the world, accounting for 21.1% of deliveries [10].In sub-Saharan Africa (SSA), it varies from 2% to 51% of deliveries [11], and in Ethiopia for 29.55% of deliveries [12], which was higher than the ideal rate of cesarean section recommended by WHO (10-15%) [13].CS was considered to be a barrier to the TIBF, although some studies revealed that it is possible to initiate breastfeeding within one hour of cesarean delivery under spinal anesthesia [14].
Despite its importance to reduce risk of neonatal mortality, only 51.9% of mothers in the south Gondar zone [15], 57% in Dessie city [16], and 51.2% in Addis Ababa [17], mothers who gave birth by CS, practiced TIBF in Ethiopia, which was lower than the national target (92%) [18].
Previous studies done in Ethiopia on TIBF focused mainly among women who gave birth by spontaneous vaginal delivery and limited studies were conducted so far among cesarean section deliveries.In addition, there is no documented study in health facilities of central Ethiopia in this subject matter.Therefore, this study aims at assessing the timely initiation of breastfeeding and its associated factors among women who gave birth by cesarean section at hospitals of Kembata Tembaro and Hadiya zones in central Ethiopia.

Study design and area
We conducted a facility-based cross-sectional study in hospitals of Kembata Tembaro and Hadiya zones in central Ethiopia from May 01 to 30, 2022.Kembata Tembaro and Hadiya zones are two of the five zones in central Ethiopia region, having a total population of 1,080,837and 1,727,920 respectively.Which are 272 km and 230 km away from the capital city of Ethiopia, Addis Ababa respectively.The estimated annual delivery was 30,286 in Kembata Tembaro zone and 23,153 in Hadiya zone.There are four hospitals that provides cesarean delivery services, 36 health centers and 138 health posts in Kembata Tembaro zone while in Hadiya zone there are four hospitals that provide cesarean delivery, 61 health centers, and 311 health posts [19].

Sample size determination and sampling techniques
We calculated sample size by using a single population proportion formula with the assumptions; the margin of error (d) = 5%, confidence level = 95% (Zα/ 2 = ±1.96),and the proportion of TIBF (p) among mothers who gave birth by cesarean section was 57% [16].So, the final calculated sample size with a 10% non-response rate was 415.
All hospitals that provide cesarean delivery services in Kembata Tembaro and Hadiya zones were included.The sample was allocated proportionally based on past CS deliveries in the identified hospitals.Wachemo University Nigist Elleni Mohamed Memorial Comprehensive Hospital (192), Shone Primary Hospital (25), Hommacho Primary Hospital (20), Gimbichu Primary Hospital (18), Shinshicho Primary Hospital (35), Mudula Primary Hospital (28), Doyogana Primary Hospital (22), and Dr. Bogalech Gebre Memorial General Hospital (75).Finally, a consecutive sampling was used to select women who gave birth by cesarean section to get the desired sample size.
The source population were all mothers who gave birth by CS in hospitals of Kembata Tembaro and Hadiya zones, while all mothers who gave birth by cesarean section in hospitals of Kembata Tembaro and Hadiya zones during the data collection period were considered as the study population.
We included women who gave birth by cesarean delivery under spinal anesthesia in hospitals of Kembata Tembaro and Hadiya zones, whereas women whose newborns were admitted to the neonatal intensive care unit (NICU) immediately after delivery were excluded from the study.

Data collection tool and procedures
Data collection tools were adapted from reviewing related literatures [20], and WHO indicators to measure timely initiation of breastfeeding.It consists of socio-demographic characteristics, information about timely initiation of breastfeeding and colostrum feeding, obstetric and health service related characteristics, maternal obstetric and medical complications related questions, timely initiation of breastfeeding questions and newborn factors related questions.The questionnaire was prepared in English and translated to Amharic and local languages (Kembatisa and Hadiyisa) and back to English by a language expert to check its consistency.
Data were collected by eight bachelor nurses and supervised by four supervisors (two master degree holders in maternity nursing and two bachelors in public health).Brief orientation was given to respondents on the purpose of the study and thus volunteers were interviewed face-to-face and their charts were reviewed.After screening the area for privacy, the eligible women were interviewed at their bedsides within 72 hours of cesarean delivery before requesting discharge from the hospital, and detailed information was collected.
The study's explanatory variables include Age, Level of education, Employment, Place of residence, Number of antenatal care visits, Type of pregnancy, Counseling about timely initiation of breastfeeding during ANC follow-up, Post-cesarean section counseling, Obstetric complications, Assistance from health professionals for timely initiation of breastfeeding, Early skin-to-skin contact with a newborn baby, Informed about timely initiation of breastfeeding, Breastfeeding experiences, Prelacteal feeding, Birth weight, APGAR score and Sex of the newborn.

Operational definitions
Timely initiation of breastfeeding: is the initiation of breastfeeding for newborn within one hour of birth.It was calculated based on responses to the question "How long after delivery did you start breastfeeding for your newborn?"The responses were recorded in hours and a binary variable of timely initiation of breastfeeding was generated (Yes = 1, if the initiation of breastfeeding was within an hour of birth, No = 0, if the initiation of breastfeeding was after one hour of birth) [15,16].
Health professionals' assistance for timely initiation of breastfeeding: is assisting the women and newborn baby for proper positioning and attachment to initiate breastfeeding within one hour of delivery.
Prelacteal feeding: is feeding any liquid or solid food other than mother's breast milk before initiating breastfeeding to the newborn baby [21].

Data quality control
To maintain the data quality, the two-days training was given to data collectors and supervisors about the objective of the study, ethical issues, and data collection methods.Tools were translated to local languages and a pretest was conducted on 5% of the total sample size at Halaba Kulito General Hospital.Based on the results of the pretest, adjustments were made as needed, and the amended tool was used for actual data collection.Supervisors closely followed the data collectors and data collectors were instructed to check the completeness of the questionnaire immediately after its completion for each participant.

Data analysis
The data were entered using EpiData 4.6 and analyzed using SPSS version 26.Descriptive statistics were used to describe the participants, and the results were presented in the form of text, tables, and figures.Binary logistic regression model was used to identify the association between each independent variable and the outcome variable.In bivariate analysis, independent variables with p-value less than 0.25 were selected for multivariable analysis.Multi-collinearity was checked by using the variance inflation factor and standard error.The model fitness was checked by the Hosmer Lemeshow goodness of fit test.Adjusted Odds Ratio (AOR) with a 95% confidence interval (CI) was reported, and p-value <0.05 were considered as significantly associated with the timely initiation of breastfeeding.

Ethical considerations
Ethical clearance was obtained from Haramaya University College of Health and Medical Sciences Institutional Health Research Ethics Review Committee (Reference number: IHRERC/ 064/2022).A letter of support was written to the study hospitals.Before starting the data collection, the medical directorates of each hospital provided their written and signed permission.Each participant was informed of the study's purpose, potential benefits, risks, and their right to decide whether to participate in the study before enrolling in it.Then informed voluntary written and signed consent was obtained from each participant.Assents were sought from participants under the age of 18, and their parents or legal guardians provided written informed consent.The participants' names were neither sought nor recorded in order to maintain confidentiality.

Socio-demographic characteristics of participants
A total of 403 women who gave birth by cesarean section participated in this study, with a response rate of 97.1%.The median age of the women was 29 years with an interquartile range (IQR) of 27 to 32 years.Of all, 168(41.7%)women were in the age group of 25-29 years and 232(57.6%)were urban dwellers.All women, 403(100%) were married, and 222(55.1%)were protestant (Table 1).

Obstetric and health service-related characteristics
In this study, 403 (100%) of the women reported that they had a history of ANC follow-up in the current (index) pregnancy, even though, 211(52.4%) of them had less than four ANC visits and 223(55.3%) of women reported they had no counseling about timely initiation of breastfeeding during their ANC visits.Regarding the place of ANC follow up 223(55.3%) of women visited in hospitals, while 180(44.7%)visited in health centers, and only 140 (34.7%) received assistance from health professionals for timely initiation of breastfeeding after delivery.In terms of the CS type, 353(87.6%) of women had an emergency CS, and only 136 women (33.7%) received post-CS counseling about timely initiation of breastfeeding, and 227(56.3%) of women started early skin-to-skin contact with their newborn baby (Table 2).

Information about timely initiation of breastfeeding and colostrum feeding
In this study, 399(99.0%)reported they had heard about the TIBF, and 245(61.4%) of the women mentioned health professionals as a source of information.Around 368(91.3%) of women were aware of the importance of colostrum feeding for the newborns but only 276 (68.5%) of the women feed it to their newborns (Table 3).

The magnitude of timely initiation of breastfeeding
Themagnitude of timely initiation of breastfeeding among women who gave birth by cesarean section under spinal anesthesia in hospitals of Kembata Temabaro and Hadiyazones was 47.4% with 95% CI:(42.5, 52.6%).

Factors associated with timely initiation of breastfeeding
After controlling for possible confounding factors having four or more ANC visits, counseling about TIBF during ANC follow-up, post-delivery counseling about TIBF, early skin-to-skin contact with newborn, and assistance from health professional's during the initiation of breastfeeding were significantly associated with TIBF at 95% confidence level with p< 0.05.Women who attended four or more antenatal care visits were 2.27 times more likely to initiate breast feeding within 1h of birth than who had less than four visits [(AOR): 2.27, 95%CI: (1.28, 4.02)].Women who obtained counseling during antenatal care on TIBF were 4.78 times more likely to initiate breast feeding within 1h of birth than who did not get counseling [AOR: 4.78, 95% CI: (2.66, 8.60)].Women who practice early skin to skin contact with newborn were 2.83 times more likely to initiate breast feeding than women who did not practice it [AOR: 2.83, 95% CI: (1.60, 5.02)], in addition women who received professional counseling during post-delivery were 2.93 times more likely to practice TIBF than who did not got [AOR: 2.93, 95% CI: (1.56, 5.50)].Compared to women who did not got professional assistant from health care provider at the time of post-natal time those who got assistance from health professionals were 3.07 times more likely to initiate breast feeding within 1h of birth [AOR: 3.07, 95% CI: (1.64, 5.75)] (Table 4).

Discussion
This study assessed the magnitude of timely initiation of breastfeeding and its associated factors among women who gave birth by cesarean section.The magnitude of timely initiation of breastfeeding in this study setting was 47.4%.Four or more ANC visits, counseling about TIBF during ANC follow-up, post-delivery counseling about TIBF, early skin-to-skin contact with newborn baby, and assistance from health professionals for TIBF were significantly associated with timely initiation of breastfeeding.
The magnitude of timely initiation of breastfeeding in this study was consistent with the finding of studies conducted in the south Gondar zone, Ethiopia (51.9%) [15], and Addis Ababa, Ethiopia (51.2%) [17].However, this finding was lower than the result of studies done in Dessie city, Ethiopia (57%) [16], Malaysia (73.7%) [22], and WHO global survey (57.6%) [23].This discrepancy might be due to difference in sampling procedure because we used consecutive sampling technique whereas they used systematic sampling technique.And this finding was higher than the results of the studies conducted in Kenya (25%) [24], and Egypt (28.1%) [25].This variation might be due to differences in the inclusion criteria (they included women who gave birth under general anesthesia, which delays the initiation of breastfeeding), study setting, and the time that the study was done.In this study, women who had four or more ANC visits were 2.27 times more likely to initiate breastfeeding within one hour of delivery than those who have less than four ANC visits.This finding was supported by the study conducted in the south Gondar zone, Ethiopia [15], Indonesia [26], Ghana [27], and Bangladesh [28].The possible reasons could be women who had frequent antenatal care visits during their pregnancy could get more chance of getting awareness about timely initiation of breastfeeding and its importance on newborn baby survival, which would help them to practice timely initiation of breastfeeding upon delivery [29].The odds of timely initiation of breastfeeding were 4.78 times higher among women who received counseling about TIBF during their ANC follow-up than their counterparts.This finding was in line with a study done in Dessie city, Ethiopia [16], Brazil [30], and India [31].This might be because counseling about timely initiation of breastfeeding during ANC followup provides information about the effect of timely initiation of breastfeeding on mother and newborn health, which motivates the mothers to plan timely initiation of breastfeeding for their newborn baby [32].
Furthermore, the odds of timely initiation of breastfeeding were 2.83 times higher among women who practiced early skin-to-skin contact with their newborns when compared with women who didn't apply early skin-to-skin contact with their newborns.This finding was similar to a study conducted in Malaysia [22], and Nepal [33].This might be due to the reason that most newborns were ready to find the nipple and latch on to the breast immediately after birth, if early skin-to-skin contact between mother and newborn is implemented, naturally the newborns have a tendency toward the breast [34].
Women who received post-cesarean section counseling about TIBF were 2.93 times more likely to initiate breastfeeding within one hour of delivery than those who didn't get post-CS counseling.This finding was consistent with a study conducted in Dessie city, Ethiopia [16], and India [31].This might be because of immediate, attentive advice and information from obstetric care providers about the importance of timely initiation of breastfeeding and its role on both maternal and newborn health, mothers are more likely to initiate breastfeeding within one hour of delivery.
In addition, the odds of timely initiation of breastfeeding were 3.07 times higher among women who got assistance from health professionals for timely initiation of breastfeeding when compared with women who didn't get assistance from health professionals.This finding was supported by the study done in the south Gondar zone, Ethiopia [15], Addis Ababa, Ethiopia [17], Bangladesh [35], and Uganda [36].This might be due to assistance from obstetric care providers for proper attachment and positioning to initiate breastfeeding within one hour of delivery, mothers get emotional well-being and inspiration, which help them to initiate breastfeeding within one hour of delivery [37].
Due to the lack of significant research on this subject and the fact that participants were not selected at random, it is impossible to draw general conclusions from this institution-based study; comparability is also challenging, which were the limitations of our study.

Conclusions
The magnitude of timely initiation of breastfeeding among women who gave birth by cesarean section delivery in the study area was low compared to the national target for timely initiation of breastfeeding (92%).Attending four or more antenatal care visits, counseling about timely initiation of breastfeeding during ANC follow-up, assistance from health professionals for timely initiation of breastfeeding, early skin-to-skin contact with newborn baby, and postdelivery counseling were factors significantly associated with timely initiation of breastfeeding.Focus should be given to assist women to complete the antenatal care follow up, start early skin to skin contact with their newborn baby and initiate breastfeeding within one hour of delivery through strengthening the counseling about timely initiation of breastfeeding during ANC follow up and immediate postnatal period by health care providers.